CASE REPORT
P. Name: Talha Azam
Age: 22 years
Gender: Male
Ethnic background: Muslim
Date of report: 31 January 2024
Name of examiner: Naila Asif
Referred by: Psychiatrist
REASON FOR REFERRAL:
The client was referred by psychiatrist for the detailed assessment of
psychosocial stressors and psychological workups such as
psychoeducation of family member regarding patient condition and for
obsession compulsions, fear, Anxiety, overthinking, handwash again and
again, ordering, checking.
EVALUATION PROCEDURE:
During the evaluation procedure the patient was assessed on different
psychometrics which include both projective and subjective tests these
include the parameters or the tools such as structured clinical interview
HAM A (Hamilton anxiety rating scale), HFD (human figure drawing), RIT
(Rorschach inability test). YBOCS Yale brown obsessive compulsive
scale .In the medical notes the patient has undergone hemorrhoids
operation, endoscopy, scalp acne , urinate drops.
BEHAVIORAL OBSERVATION:
The patient was cooperative and motivated during the sessions wearing
neat and clean clothes such as shalwar Qameez. Looking appropriate to
his age. He is maintaining appropriate eye contact during the whole
session. He is oriented well to time place and the person. His mood is low
and he is anxious during a session. The speech of patient is fluent and
coherent with his mood. The patient is anxiety about obsessions and
compulsions. Abnormal thought is reported the patient is suspicious about
things hand wash and other things. Perception is not reported. He is
cooperative and motivated though out all her session. He completed all
her task on the time and came for every session on time and well dressed.
PAST PSYCHIATRIC HISTORY:
The patient reported that he was being treated by a psychiatrist
continuously for 3 years. Record not available.
BACKGROUND INFORMATION:
Mr Talha was a young highted Muslim boy and he belong to middle social
economic status. He is unmarried and he lives in joint family. He lives in
upper dir. His father is died and mother are alive. He had did his BS art
designing and never did any job he has four siblings and they are boys
and he has 1 sister .no one is married.
HISTORY OF PRESENT ILLNESS:
Mr Talha reported that obsession compulsions, fear, anxiety, overthinking,
hand wash again and again, ordering, checking, from last 3 years and the
precipitating factor is the urine drops were coming out.
FAMILY HISTORY:
Mr Talha reported that he is living in a joint family. Mr Talha is BS art
designing from Peshawar university and he is a good and stable
relationship with his family members and he is very caring towards family.
He had one sister she is unmarried doing her own study. He had a mother
she is diabetic and she was a house wife. Family disease is chest infection
and diabetes. Father has passed away.
MEDICAL HISTORY:
Mr Talha reported that they had a recently treated endoscopy and urinate
drops was also treated three years ago.
PERSONAL HISTOR:
Mr Talha reported that he had achieved all his developmental milestones
on the time and got puberty at the age of the 13 and responded good to
it. Mr Talha reported that be suspicious from childhood. Fixing things
repeatedly in since childhood. He had many friends and enjoy the life and
he had an interest in drawing in playing cricket with friends. He reported
that he did his BS art designing and he was very good in the studies. He
got 782 marks in matric and 890 marks in FSC. No problems in school
reported. He never did any job.
TEST ADMINISTRATION
YBOCS (Obsessive compulsive rating scale)
HAM A (Hamilton anxiety rating scale)
HFD (Human figure drawing)
RIT (Rorschach inkblot test)
SPM “Standard progressive matrices
INTERPRETATION AND IMPRESSION:
HAM A was applied on the patient which shows moderate to severe level
of anxiety in the patient which causes stress and the disturbance in the
patient life. YBOCS was applied on the patient which results indicates
severe to extreme obsessive compulsions due to which she is unable to
continue her daily life activities. Projective test such as
HFD was applied on client which shows desire for affection, nurturance
needs, narcissism infantile or repressed sex desires, dependency, difficulty
with interpersonal relation, masturbatory guilt, homosexual anxiety,
anxiety, timidity, uncertainty, social dependency, social accessibility,
social communication, passive homosexual, conflict or tendency, sensitive
attitude for others.
Standard progressive matrices was applied on patient which results shows
definitely below average.
Rorschach inkblot test was administered and its interpretation indicate
that the person has lack of interest in seeking relationship, dependency,
criticism, immaturity, need of affection, critical, anxiety, impulsivity,
poorly adjusted, creative potential. Insecurity and feel safest when sticks
close to the obvious dependency.
TAT have been administered that the tat protocol suggest that the main
theme is anxious and thinking about future, the patient had a poor self
image, his significant conflict achievement and succorance, and
behavioural need for achievement conception of environment stressful
and suspicious. The nature of anxiety of the subject seems to deprivation
and helpless. Future to reduce anxiety. He uses defence mechanisms
repression, regression, his ego functioning inappropriate, unrealistic,
inadequate, unhappy, and have below average.
TENTATIVE DIAGNOSIS:
Obsessive compulsive disorder (300.3 “F 42”)
SUMMARY:
The patient present the symptom of obsession compulsions, fear,
anxiety, overthinking, hand washing again and again, ordering, checking,
and a psychometrics both objective and projective tools are administered
on the patient in the whole process of the assessment and diagnosis and
identified problems obsession and compulsions, overthinking, aggression,
disturb sleep and treatment according to the problem used in
psychoeducation of patient and family , the behavioural techniques such
as relaxation ( deep breathing) , anger management, CBT “Obsessive
compulsive disorder” skills such as obsessive compulsive cycle, spot light,
identify cognitive distortion, challenge thoughts with exposure
“experiments” behaviour activation schedule, sleep hygiene, imaginary
desensitization, mindfulness relaxation techniques “ Broken dam, band of
light, save place visualization, imaginary techniques was used with the
patient problems under the structured session in hospital.
PROGNOSIS:
Prognosis of patient is good as he had a good insight about his condition
and he is very cooperative and the motivated about his treatment and
come for regular follow up with psychiatrist and for booster session.